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Supporting health and social care providers in Devon

Market Position Statement - summary

MPS: Executive Summary

1. Demographics and need analysis

1.1 Addressing the challenges of a rapidly changing demographic profile has required a strong commitment to a strengths-based approach and to promoting the independence of those we support. The satisfaction of the people of Devon with our services continues to be high, although the biennial survey of unpaid carers raises some concerns that we need to address, especially in relation to replacement care

Chart showing service user experience measures – Devon patients have more access (81.8%)to GP appointments compared to the rest of England (68.7%).

1.2 Although the population of older people has continued to grow, we spend more of our budget on working age people than those aged over 65. This reflects our success in promoting independence of older people, coupled with the community, familial, and financial resources available to them.

1.3 as we look to the future we need to plan for a different profile. There was a lull in the birth rate between 1925-1942 and these people are now aged between 77 and 94. From 1943-74 there was a peak in the birth rate and these people are now aged between 45-76 – the ‘baby boomer’ generation. We can expect an extended surge in demand for adult social care over the next thirty years, with needs associated with this population increasing by approximately 20% over the next two decades.

1.4 The diagram below illustrates this peak in population:

Trend in total births across England and Wales (increased births about 25 years apart) shows that there was a lull in the birth rate between 1925-1942 and these people are now aged between 77 and 94. However from 1943-74 there was an extended peak in the birth rate and these people are now aged from 45-76 - the 'baby boomer'generation.
Trend in total births across England and Wales (increased births about 25 years apart) shows that there was a lull in the birth rate between 1925-1942 and these people are now aged between 77 and 94. However from 1943-74 there was an extended peak in the birth rate and these people are now aged from 45-76 – the ‘baby boomer’generation.

1.5 People with physical and learning disabilities, sensory needs and/or autism are living longer with more complex needs. Peaks in demand typically occur:

  • following transition to adulthood, often with high levels of need
  • in middle age, due to the ageing of their carers.

1.6 In line with national trends there is an increasing prevalence of need for people with autism and this will be a growing pressure for decades to come.

1.7 The profile for people with mental health needs (not including dementia) is more evenly distributed across the life course.

1.8 It costs five times more to look after someone who is 85 or above than a 30-year-old, with those costs concentrated in the last two years of life.  When factoring in the prevalence of dementia for those aged 85+, the demand for health and social care will become more pronounced. Trends already show that, after a period of relatively stable death rates, these start to climb sharply over the next decade, as will the need to support them at the end of life.

Trend in number of deaths and future projections in Devon. It can be seen that, after a period or relatively stable death rates these start to climb sharply over the next decade.
Trend in number of deaths and future projections in Devon. It can be seen that, after a period or relatively stable death rates these start to climb sharply over the next decade.

2. Context and wider impacts on demand:

2.1 The future development of the health and care system will be underpinned by:

  • collaboration – engaging providers in whole system redesign and innovation
  • prevention – promoting well-being and independence throughout life
  • integration and partnership – across the health and care system and with independent sector providers and the community and voluntary sectors
  • outcomes and personalised services – “what matters” to the individual
  • innovation – transforming services to respond to changing models of care that support people in their own homes wherever possible
  • use of technology – including being ‘digitally enabled’
  • workforce – developing rewarding careers across the health and care system.

2.2   At the heart of this approach is the Integrated Care Model, the blueprint for Devon’s integrated networks of community and hospital services, which will:

  • connect people with things that help them live healthy lives
  • support people to stay well and independent at home
  • proactively avoid dependency and escalation of illness
  • connect people with expert knowledge and clinical investigation
  • ensure easy access to urgent and crisis care
  • embed end-of-life care at all levels.

2.3 The MPS also considers a number of wider impacts on demand including:

  • population growth, rising by 33,000 people over the next five years
  • an increase in the number of people who are living for longer in ill-health
  • an increase in preventable illnesses, such as diabetes
  • rapid changes in the volume and nature of demand.

 

3. Market overview

3.1 The MPS considers a range of factors that will affect markets including:

  • the wider economic context and challenges to the viability and cost-effectiveness of provision, especially in deep rural areas
  • quality – which is generally higher than comparators and regional averages
  • workforce – significant difficulties in securing and retaining the workforce
  • sufficiency – which is highly challenging but varies across markets
  • experiencing fast-changing profiles of need – and impact on models of care and workforce balance
  • patterns of investment and suitability of buildings
  • the pattern of supply and its ability to respond across the whole county
  • potential for innovation
  • the needs and contribution of unpaid carers
  • the potential impact of Brexit.

 

4. Quality, Contract Management and Market Strategy

4.1 The proportion of regulated adult social care services in Devon rated ‘Good’ or ‘Outstanding’ is better than comparator and national averages.

The following chart is taken from the Care Quality Commissioning (CQC) local area reports. This shows the proportion of regulated adult social care services in Devon rated Good or Outstanding is better than the comparator and national averages.

The map of Devon shows the proportion of regulated adult social care services in Devon rated Good or Outstanding is better than the comparator and national averages.
The map of Devon shows the proportion of regulated adult social care services in Devon rated Good or Outstanding is better than the comparator and national averages.

4.2 The Council and NHS also have a wider responsibility to promote quality across all sectors. The Supporting Independence contract, for instance, sets quality standards for unregulated care and support, with commissioners working with suppliers on quality improvement through our Quality Assurance and Improvement Teams, which take assertive but supportive action to address quality concerns with providers, whether registered or unregistered.

4.3 Our commitment to effective provider relationships has been strengthened by the development of the DCC and CCG Market Development Teams. This will enable us to give additional focus to:

  • supplier relationships and contract compliance by all parties
  • building market strategies with providers.

4.4 Many people choose to take their personal budget through a Direct Payment,  50% of whom purchase or employ a social care personal assistant (known as a PA) which make up 9% of the social care workforce. Commissioners do not directly quality assure PAs but do offer guidance to people through our PA Network, which is hosted on the Pinpoint Devon website.

 

5. Workforce

Arguably the biggest challenge to delivering sufficient, high quality markets is the availability and quality of the workforce.

5.1 Devon’s employment

The highest ever number of individuals were economically active during the past 18 months, at 82.6%.  50,000 more people are in work compared to 2004 (17% increase). Claims for Job Seekers Allowance are at the lowest sustained level for 20 years at 1.4%, roughly 1.5% below the national average.

5.2 Growth in the Health and Social Care Sector

5.2.1 The health and social care sector grew 37% between 2007 and 2017, despite the economic downturn and increased in value across the Heart of the South West by £1bn.  The sector is expected to grow twice as fast as the rest of the economy over the next decade and will comprise 25% of the Devon economy by value compared to approximately 21% today.

5.2.2 The Devon economy has the tightest labour market for at least a generation

People have a real choice when looking for new roles in the current labour market and health and social care will need to be competitive to attract the right workforce.

5.2.3 Health and Social Care vacancies make up 20% of all advertised roles, with many posts difficult to fill, despite the range of attractive posts and career options. Previously lower value areas are overtaking the social care subsector (accommodation / tourism / administration) in terms of salaries, with retail not far behind.

5.3 The Adult Social Care workforce

5.3.1 There are 24,000 jobs in adult social care in Devon, 95% of which are in the independent sector.  Turnover is at 34.0% and there is a vacancy rate of 5.4%.

5.3.2 Skills for Care estimate that the number of adult social care jobs in the South West region will need to increase by approximately 43% by 2035.

Staffing -m adult social care turnover and vacancy: graphs providing information on estimated levels of staff turnover where in 2015-2018 Devon has a higher rate in 2016/17 but lower rates of staff vacancies overall 2015-2018.
Staffing -m adult social care turnover and vacancy: graphs providing information on estimated levels of staff turnover where in 2015-2018 Devon has a higher rate in 2016/17 but lower rates of staff vacancies overall 2015-2018.

5.3.3 The majority (82%) of the workforce is female and the average age is 43.5 years old. Those aged 24 and under make up 11% of the workforce and those over 55 represent 27%.  Skills for Care estimate that 89% of the workforce in Devon have a British nationality, 7% are from within the EU and 4% from outside the EU.

5.3.4 Less than a fifth (17%) of the workforce are on zero-hours contracts, although it is higher in some sectors, with many employers reporting that it is difficult to get existing staff to transfer to contracted hours as they prefer the flexibility of a zero-based contract. Our view, however, is that we need to encourage guaranteed hours contracts and shift patterns if we are to achieve quality and sufficiency.

5.3.5 A key consideration over the coming years will be on how we can improve the pay rates and wider terms and conditions for the social care workforce but any change to unit rates needs to be linked to improved efficiency and productivity across the health and social care system.

 

5.4 Supporting workforce development

Proud to Care Devon is the single workforce brand for all health and social care organisations in Devon and supports care and health providers to:

  • attract high quality applicants, with the right values
  • develop career pathways in care and health e.g. promoting the new Nursing Associate apprenticeship
  • retain staff within the care and health system in Devon
  • train and develop staff e.g. through Leadership and Management programmes
  • promote good employment practices
  • celebrate and value high quality staff.
Proud to Care website screen-shot of job search page view
Proud to Care website screen-shot of job search page view

6. Brexit

6.1 The effect of Brexit on the health and social care market is unclear. The main concerns for providers relate to

  • availability of fuel – we estimate 56,000 miles per day are travelled in the personal care market alone, requiring approximately 1,400 gallons of fuel
  • price increases – especially for providers with restricted cash flow
  • availability of medicines and medical supplies
  • continuity of food supplies
  • supply chains for other consumables.

Contingency planning has been undertaken and we will carefully monitor any impact.

 

7. Technology

It will be ever more important to harness new technology, beyond the Technology Enabled Care Services (TECS) solutions that are already available. We will need new approaches to stimulating innovation, to meeting and changing expectations and to finding new solutions to both support people and find service efficiencies, including use of digital technologies. We are interested in discussing with providers how we can both innovate within individual businesses or sectors and take a more strategic approach to stimulating innovation.

 

8. Unpaid carers

8.1 Unpaid carers need to be at the heart of all we do, including recognising that an increasing number of people in the workforce are balancing work with caring responsibilities. Carer-aware employment practices will be increasingly important.

8.2 The Commitment to Carers, adopted by the STP, recognises that this is crucial both to support the workforce and improve efficiency and profitability.

8.3 More widely, a great deal of work is under way to provide high quality information and advice, training, peer and other community support to unpaid carers, with our approach currently subject to a Scrutiny Spotlight Review.

8.4 The biggest issue for carers within the MPS relates to the need for improved access to replacement (respite) care which they can pre-book.

 

9. Rurality, access to services and lifetime planning

9.1 Ensuring sufficiency is challenging across Devon because:

  • it is increasingly difficult to secure the workforce to cover our rural communities, especially where people require, for example, double-handed personal care, often 4 times per day
  • some services are not economically viable at a highly localised geography (especially care homes with nursing)
  • the costs of delivering care to deep rural areas (even if the workforce were available) may be prohibitive.

9.2 We all need to think about the decisions we need to take to prepare for, or respond to, fragility, ill health or disability, including where we live.

9.3 Our health and social care system will need to continue to have an open dialogue with our citizens about the expectations they can have of service delivery

 

Sufficiency assessment

There are four major priorities that emerge from the MPS:

  • Improving supply of care home placements for people with learning disability, complex needs and behaviours that are challenging. Current estimates are that there is a shortfall of approximately 40 places, with some people placed out of the Devon area as a result.
  • Addressing a shortfall of circa 2,600 hours per week in the regulated personal care market, 75% of which is concentrated in Mid Devon, Exeter and South Devon.
  • Delivering alternative care with accommodation solutions, especially in relation to Extra Care Housing and Supported Living and developing solutions to improve access to replacement (respite) care
  • Addressing shortfalls in the unregulated market to secure sufficient support to people with disabilities, mental health needs and autism through our Supporting Independence contract.

Further detail is discussed below:

10. Accommodation-based services

1o.1 This section examines:

  • care homes – with and without nursing
  • Extra Care housing
  • supported living
  • host family care.

10.2 Any consideration of sufficiency has to account for a number of features:

  • People with a similar profile may have their needs met in any of the options set out above, depending on their context, family and community supports, the shape of the local market and their choices
  • Some people who have an eligible need will choose to meet it outside of their local area e.g. to be nearer to family
  • The potential mismatch between the profile of supply (including the suitability of buildings) and the needs of the population
  • The balance between current demand and projections of future demand
  • The impact of private purchases and purchases from other local authorities.

 

11. Overall assessment

At first sight, there are enough beds overall in care homes to meet short to medium term need but there are some specific short – term issues (see below) and a more significant longer – term realignment is indicated. Some people are having to travel further to find the right care home to meet their needs.

Without a change in supply of care home places we will face a shortfall by 2028. We are currently experiencing pressures in finding places for people with learning disability and dementia and those with complex mental health needs. There has been an increase of 28.7% of people with a primary support need of memory cognition in last 12 months.

11.1 Our assessment is that:

  • Some people in care homes with nursing could have their needs met in other locations, freeing up spaces for those with need for nursing oversight 24/7
  • Care homes will increasingly be required to meet the needs of people who are more dependent and who have complex needs, especially with mental health needs (including dementia).   Not everyone with such need requires 24/7 nursing oversight
  • An increasing aspect of our work with care homes will be greater emphasis on short-term placements as we support people to recover (especially if placed straight form hospital) and move to alternative arrangements
  • There is an oversupply of Supported Living in some areas (mainly because of the way the market developed historically) which needs to be rebalanced geographically. An updated needs assessment will inform this change
  • Carer Household (host family) support has the potential to grow to offer new alternatives, including in offering replacement care.

 

11.2 The interrelationship between these sectors is clear and we are signalling a number of changes through the MPS. We expect to see:

  • Increasing complexity in the profile of people in care homes with nursing, particularly relating to people whose behaviours require careful management and/or who have dementia or mental health needs
  • The needs of people in care homes without nursing becoming more complex, requiring change to the support of community health services to those homes
  • The profile of residents becoming increasingly frail as we support more people for longer in their own homes
  • An increased range of housing and clearer pathways and pipelines to make it easier for people to move between different housing options as they develop their independence and live their lives. Indeed, some younger people are already moving from care homes into Supported Living – 56 people under 35 have been identified to date.

 

11.3 To achieve these shifts we will need to:

  • Ensure that the ‘care homes estate’ is fit for purpose and ‘technology-ready’. This will need investment in the next 5-10 years
  • Invest in the workforce to achieve the right skills to respond to the changing profile of need to deliver different models of care
  • Continue to expand the supply of extra care housing, adding in excess of 2000 units to the current stock by 2033
  • Recommission supported living, to ensure the right profile of supply
  • Work carefully with planning and housing departments.

Market Sector Assessments

12. Care homes

12.1 We buy 2,539 beds (as of 1 September 2019), costing £1,92m per week. There are 67 care homes with nursing (with 2863 beds) and 266 care homes without nursing (with 5273 beds). DCC and the NHS buy circa 31% of the registered beds across Devon.

12.2 Our area has more residential beds, fewer nursing beds, and fewer beds overall relative to population than both comparator and national averages, although this declined by 2% in residential beds and 1.6% in nursing beds in the last year.

Service provision - adult social care service provision: Number of residential and nursing care home beds for the population of Devon local authority as at 18/07/19. As a comparison to England Devon has 5275 and England has 4599 average. Nursing care beds for Devon 2863 and England average 4336. The Devon County Council area has more residential beds, fewer nursing beds, and fewer beds overall relative to population than both comparator and national averages. It also experienced a decline of -2% in residential beds and -1.6% in nursing beds.
Service provision – adult social care service provision: Number of residential and nursing care home beds for the population of Devon local authority as at 18/07/19. As a comparison to England Devon has 5275 and England has 4599 average. Nursing care beds for Devon 2863 and England average 4336. The Devon County Council area has more residential beds, fewer nursing beds, and fewer beds overall relative to population than both comparator and national averages. It also experienced a decline of -2% in residential beds and -1.6% in nursing beds.

12.3 We place fewer older people in residential/nursing care relative to population than comparator and national averages. Short-term services are effective at keeping people out of hospital and independent but don’t reach enough people, partly because capacity is diverted as contingency for personal care insufficiency.

Service provision - short-tern treatment outcomes and long-term care home admissions. This chart and tables shows the rate of council supported older people (aged 65+) whose long term support needs were met by a change of setting to residential or nursing care during the year per 100,000 population.
Service provision – short-tern treatment outcomes and long-term care home admissions. This chart and tables shows the rate of council supported older people (aged 65+) whose long term support needs were met by a change of setting to residential or nursing care during the year per 100,000 population.

12.4 The largest cohort is aged 90+ with 786 placements and 85-89 with 576 placements. 49.2% of all care home placements are for people over the age of 85.

12.5 The trend of placements is shown in the graph below, which illustrates a net increase in the numbers of placements made over the last year:

Devon County Council funded residential clients 12 month trend (increases in September from 2060 peaking at 2820 (approx) in May 2019 then falling a little in July to 2750 approx.
Devon County Council funded residential clients 12 month trend (increases in September from 2060 peaking at 2820 (approx) in May 2019 then falling a little in July to 2750 approx.

12.6 53% of people who required a placement in a residential care home and 43% in a nursing home sourced a placement in their own market town area. Further detail will be supplied when our needs assessment is updated early in 2020.

12.7 While it is possible to sustain a local supply of care homes without nursing, Supported Living, Extra Care Housing and carer households, it is much more difficult to achieve for care homes with nursing. Economies of scale mean that fewer, larger, more modern nursing homes are likely to be needed in strategic locations.

12.8 Greatest pressure on nursing home places is evident in Teignbridge, East Devon, Exeter and North Devon with Barnstaple, Newton Abbot and Exeter as locations where additional, modern nursing home capacity is most likely to be viable and to meet need.

12.9 Actions to support the care home market:

  • An Expression of Interest was launched 2/10/19 to seek placements for people with complex needs and discussions will follow with providers about the best contractual vehicle to underpin those purchases
  • A survey of the care homes estate will shortly be complete to inform future investment decisions
  • An updated needs assessment will be published in Spring 2020 to further clarify future requirements and reshape the care home market
  • Local needs profiles will be developed, working closely with care homes to reshape the market
  • Work with providers and communities to increase the range of housing and develop a clear pathway and pipeline to make it easier for people to move between different housing options as they develop their independence and live their lives.
  • We will target areas that are overly- reliant on care homes without nursing and work with the market to change the offer. This may mean supporting care homes to develop their community-based offer (including deregistration)
  • Early work with young people to prevent transition to residential care
  • A new joint DCC and NHS open framework contract for all care homes for all adults will be introduced in 2020/21
  • A regional framework for care homes for people with more complex and intensive support needs associated with a learning disability is planned for 2020
  • Consideration of new workforce models including Nurse Associates
  • Workforce planning through the PEN and ‘Proud to Care’ initiative, including particular consideration of the most effective models for employing nurses and the emerging nurse associates
  • Promote the use of assistive technology to support independence
  • Work with NHS colleagues and Care Homes in the implementation of enhanced health care in care homes which is designed to improve the quality of life, healthcare and planning for people living in care homes.

 

13. Extra Care Housing (ECH)

13.1 We buy 90 places (as of 1 September 2019) costing £16,647 per week = 26% of the schemes in which we commission.

13.2 This service offers an alternative to residential care as well as providing a further option for clients being discharged from Hospital. The Council has made capital support available to develop new provision and continues to invite new and innovative approaches to achieve affordable schemes. It is intended to extend the provision to more people with dementia and to working age adults.

13.3 Each ECH scheme is likely to have approximately 60 or more units of accommodation to achieve maximum economies of scale. Approximately one third of people living in ECH are anticipated to have social care needs equivalent to those of people living in care homes without nursing

13.4 Since 2010, the Council has enabled the development of new extra care housing schemes in Newton Abbot, Bideford and Totnes, with new Schemes in development or with planning permission in Exeter and Tiverton. Sites have been identified for 2 further schemes in Barnstaple and Kingsbridge. An application for outline planning permission has been submitted for a site in Barnstaple which includes the provision of circa 60 Extra Care Housing flats.

In operation
Okehampton

Castle Ham Lodge

 

50 units social rented
IvybridgeDouro Court

32 units social rented

 

Newton AbbotHayden Court

50 units affordable rented

 

 

Bideford

 

 

Moreton Court

 

41 units affordable rented

18 units shared equity

 

Totnes

 

 

Quayside

30 units – affordable rented

30 units shared ownership

Planned

Exeter

 

 

St Loyes

53 affordable units for rent. Completion in 2020

 

Tiverton

 

Alexandra Lodge45 affordable units

 

13.5 Demand for extra care housing comes from:

  • Devon County Council commissioned activity – over 30% as an  alternative to care homes without nursing
  • Local housing authorities
  • NHS
  • Self-funders.

13.6  Net demand for ECH, taking into account the current or planned supply. An additional 1100 places are currently required to meet the need (and this will grow through to 2033) as shown in the following locations:

LocalitiesCurrent Unmet Commissioned NeedProjected commissioned demand @ 2033
Exeter151252
Exmouth121189
Newton Abbot / Kingsteignton87195
Barnstaple85150
Teignmouth3970
Sherford043
Dawlish3258
Kingsbridge3659
Seaton3758
Sidmouth5383
Tavistock4894
Crediton3161
Axminster4265
Cranbrook055
Cullompton4179
Ilfracombe / Braunton / Lynton / Lynmouth58103
Dartmouth2033
South Molton2544
Honiton4672
Ashburton/Buckfastleigh2240
Great Torrington2652
Moretonhampstead1425
Holsworthy2551
Okehampton635
Ottery St Mary3655
Tiverton1063
Ivybridge3559
Totnes-1417
Bideford/Northam570

 

13.7 Actions to support the Extra Care Housing Market

We want to work with providers who can:

  • Facilitate the design and construction of Extra Care Housing in areas of need
  • Secure a significant proportion of the funding to finance the construction and operation of Extra Care Housing – including the servicing of any debt
  • Operate Extra Care Housing and provide or arrange facilities management services
  • Provide or arrange core care services
  • Provide or arrange personal care and support services
  • Engage with communities and partner with other services.

To encourage market development, capital may be available to invest in the design and build phase of schemes.

Providers are encouraged to contact us to discuss potential developments in any of the areas of unmet need set out in the table above.  Priority areas for extra care development are Exeter, Exmouth, Teignmouth, Sidmouth, Tavistock, Axminster, Honiton, Ilfracombe.

 

14. Supported living

14.1 We buy 489 places (as of 1 September 2019) costing over £333 per week. Any private purchase into this market is minimal.

14.2 Supported living involves shared care support but where people have their own accommodation. It offers an alternative to care homes and is currently focused on working age people as cost-effective models have not yet been evidenced for older people.

14.3 Some areas, such as Exeter, have high levels of vacancies and we are working with providers in those areas to address the consequences of this over – supply.

14.4 There have been a number of acquisitions of supported living properties from large companies outside of Devon, including hedge-fund backed investors and this may create some vulnerability to the pattern of supply.

14.5 Actions to support this market are:

  • individual work with providers to adapt their businesses
  • a supported living sufficiency assessment is under way to match need with available supply. A detailed update to the MPS will be provided once that is complete. A revised needs assessment will report in early 2020.

 

15. Carer households

15.1     We buy 102 places for people aged 16+ at circa £31,000 per week. This is 100% of the market.

15.2     There is potential to extend the use of such placements, especially in relation to supporting people with more complex needs.

15.3     Actions to support this market:

  • Create dynamic carer households to support people with a range of needs as short-term respite or to develop independent living skills, from age 16.
  • Identification of carer households who want to continue to support people with a low level of needs alongside a more bespoke smaller cohort of carer households who are comfortable with supporting people with more complex needs – and working with them to enable them to do this.

 

Community (non-accommodation-based) services

A number of sections in the MPS address those market sectors where accommodation is not part of the commissioning;

  • Living Well at Home – our regulated personal care contract
  • Supporting independence – 1:1 support for people which does not need to be regulated by CQC (most frequently for people with a learning disability or mental health need) and group-based services (day care)
  • Carers – support to unpaid carers
  • Replacement care (though can also be accommodation-based)
  • TECS – Technology Enhanced Care and Support
  • Individual purchasing – Direct Payments, Individual Service Funds and self-funders.

 

16. Regulated personal care

16.1 The County Council buys 33,500 hours of personal care a week and the Northern, Eastern and Western Devon Clinical Commissioning Group, more commonly (known as NHS NEW Devon CCG) about 5,000 hours. This represents 70-80% of market.

16.2  80% of all commissioning is now through our Living Well@Home service, which operates in eight zones:

Map of Devon by zone areas 1-8 Listed in below table
Map of Devon by zone areas 1-8 Listed in below table
Geographic ZoneDescription 
1Bideford/Northam, Great Torrington and Holsworthy
2Ilfracombe, Lynton/Lynmouth, Barnstaple, South Molton
3Tiverton, Crediton, Cullompton
4Exeter
5Honiton, Sidmouth, Exmouth, Seaton
6Newton Abbot, Totnes, Dartmouth
7Tavistock, Ivybridge
8Okehampton, Moretonhampstead

 

16.3 Demand remains comparatively stable but there is some evidence of a growing complexity and intensity in the level of need and volumes are likely to grow in line with demographic projections.

16.4 As at 6 December 2019, there were 2654 hours of unmet need relating to 255 people. This equates to a shortfall of approximately 100 carers. The map below shows the distribution of the unmet need.

This map of Devon is colour coded to show how many people who are waiting for ‘Living Well at Home’ personal care.

The map below shows this graphically, with each circle representing a person. It is important to stress that each of these people either has care in place (but not solely from the Living Well at Home contract) or is safe and well while they are waiting for care.

This map of Devon is colour coded to show how people who are waiting for 'Living Well at Home' personal care providers, October 2019 Blue – at home awaiting care Black – in hospital awaiting discharge Pink – in a temporary care home placement Yellow – covered by Rapid Response or Social Care Reablement pending market supply (is the majority) Grey – at home, need partially filled but some outstanding need.
This map of Devon is colour coded to show how people who are waiting for ‘Living Well at Home’ personal care providers, October 2019
Blue – at home awaiting care
Black – in hospital awaiting discharge
Pink – in a temporary care home placement
Yellow – covered by Rapid Response or Social Care Reablement pending market supply (is the majority)
Grey – at home, need partially filled but some outstanding need.

16.5 The majority of people are receiving care, but with 75 people waiting at home, supported by family, friends and community

Hours of care unsourced is 2,654.25 and 165.50 sourced in mid December 2019: 14.5% Northern, 46.6% Eastern, 38.9% Southern
Hours of care unsourced is 2,654.25 and 165.50 sourced in mid December 2019: 14.5% Northern, 46.6% Eastern, 38.9% Southern

At a zone level as at mid-December 2019 the unmet need is:

ZoneNumber of hoursNumber of People
116415
222131
339630
446556
526919
685178
718015
810611

 

16.6 Need varies at locality levels and we are developing zone level market strategies, to be shared with the market during 2020.

16.7 Challenges for this market relate primarily to:

  • workforce availability and the consequential impact on sufficiency
  • largely full employment, reduced availability of a workforce from overseas and a seasonal nature to workforce availability
  • reaching deep rural locations where remoteness is the issue and other settings, including urban settings, where competition for workforce is a greater factor
  • ensuring timely and effective transfer of people between hospital and home as soon as individuals are medically fit to leave, especially where the flow through the hospital is rapid
  • a specific concern about the responsiveness of the market to end of life care, especially where it emerges without care having been previously  provided to the person.

16.8 Actions to support the market include:

  • reducing demand by
    • focusing on strengths-based work and promoting independence
  • use of TECS;
  • contractual approaches where commissioners commit to a defined volume of hours from the market
  • giving enhanced flexibility to providers to adapt packages of care as need changes
    • community action to find local solutions to meeting need and enriching the lives of vulnerable people
  • improving efficiency with the market by
    • finding most efficient “runs” that minimise travel time
    • allocating reviewing officers to work with providers to make adjustments to care packages quickly to release capacity and consider how technology might make a contribution to better meeting need
    • learning from our Individual Service Fund pilot (see section on individual purchasing)
    • use of technology and other aids to give people maximum opportunity to be independent
    • building our approach to Outcomes Focused Commissioning
    • an examination of the costs to provider partners of running their businesses, together with their profit expectations and productivity so that we can deliver an incentivised system that can pay staff well, support sustainable businesses and deliver value for money
  • increasing supply by:
  • a temporary purchase of 1300 hours per week from national agencies to bring extra capacity to meet priority need, especially end of life care
  • improved terms and conditions of employment for care workers including guaranteed hours/shift working, coupled with improved training that upskills and provide career development opportunity
  • a commercial review of the Living Well at Home contract and the price paid for care
  • continued development of our Proud to Care campaign which celebrates care and encourages people to join this workforce.

16.9 We intend to use an organisational development approach, driven by values-based leadership, taking action with the involvement of all parts of the system.

16.10 At the heart of this challenge is the way we recognise, value and reward the workforce and further consideration needs to be given to whether care workers can be paid better than currently to attract and retain them.  Care workers are typically being paid in the region of £9 per hour, although with travel time this sometimes results in pay closer to the national living wage. We need to look carefully at a competitive rate of pay and terms and conditions of employment for this sector.

 

17. Supporting Independence

17.1 We buy:

  • 24,718 hours (as of 1 September 2019) of enabling for 1,905 people at a cost of circa £450,000 per week.
  • 383 individuals received day care at a cost of circa £47,000 per week (as of 1 September 2019).

17.2    Unregulated care and support is primarily arranged through the Supporting Independence (SI) contract which delivers both group-based day opportunities and 1:1 enabling support for new packages of care or following review.

17.3    The number of people receiving unregulated care and support has remained stable at around 2,700 at any one time across the framework and historic contract arrangements. This includes support provided within an accommodation-based environment such as supported living. People with a learning disability and/ or a mental health condition are most likely to need unregulated care and support.

Support provided into people’s own homes:

01 January 201921 August 2019
Older people331352
Older people with mental health conditions2728
People with a physical disability220231
People with a learning disability11641180
People with a mental health condition235255
People with autism112145
TOTAL2,0862189

 

The number of people accessing group based care through the SI contract and day opportunities:

01 Jan 201921 Aug 2019
Older people352369
Older people with mental health conditions32
People with a physical disability8585
People with a learning disability193200
People with a mental health condition1012
People with autism98
TOTAL651674

 

17.4  As this form of support is unregulated, the contract includes minimum quality standards, set by Devon County Council. This has informed a quality improvement programme with providers.

17.5   The framework opens annually to new providers and the range and, following the 2018 entry point, the volume of providers who are participating has grown to from 33 to 51 for group – based providers and from 47 to 67 to providers of individual support.

17.6   Challenges for this market include the need for greater capacity to deliver skilled and specialist mental health packages that could support:

  • people who are ready to leave hospital and residential care settings
  • people living in the community through crisis and reduce the need for hospital admission or residential placement.

And greater capacity to deliver skilled and specialist mental health packages that could support:

  • innovation to support people to become more independent and achieve their care plan outcomes as their needs change, including accessing community opportunities and pathways to employment
  • Improved speed of response to referrals across all service user groups for packages of individualised support
  • innovation around the challenges of how to deliver services in rural areas where there is significant travel time and few other packages in the location
  • innovation to support people to become more independent and achieve their care plan outcomes as their needs change.

17.7    Action we will take to support this market includes:

  • Undertaking a revised profile of need, which will be published by May 2020 to inform provider business plans and the future recommissioning of this service.
  • Developing a digital, live platform (currently in progress) that will provide more detailed information on:
    • Providers by post code/geographic location
    • Providers delivering packages of care by location
    • Care groups being supported by each provider

This will enable providers to target their investment decisions and long-term service developments through

  • encouragement of providers of day services that are not already on the Supporting Independence contract to join it at the next opening in 2020, especially in South Devon, recognising that, although demand is falling this remains a choice for some people
  • reducing the level of spot contracting activity and ensuring that the framework providers are used more.

 

18. Individual Purchasing

18.1  As at 1 September 2019 there were 2,157 people taking a Direct Payment (DP) at a cost of c £462,000 per week and a pilot cohort of six clients with an Individual Service Fund (ISF) at a cost of £7,500 per week. The scale of private purchase is not known.

18.2  People choose Direct Payments to purchase a more personalised market response that may differ from the traditional offer.

Direct Payments are not suitable for everyone and we need to find alternatives for those who don’t want the responsibility of managing a personal budget themselves, as well as those who may lack the capacity to do so. A family member or a ‘Suitable Person’ isn’t an option for many people.

An Individual service Fund (ISF) could be such a solution for those who want choice and control but who need support to manage their personal budget.  The ISF offer, has the potential to stimulate a market to provide some support, but which also creatively sub-contracts and purchases from elsewhere to meet the service user’s needs and outcomes more effectively.

The Council and NHS are testing various forms of outcomes-based commissioning within individualised purchasing arrangements to encourage and support the market to work in this way.

18.3  Direct Payments (DP) represent 15% of the net Adult Care & Health operational budget and represents a spend of circa £26m per annum.

18.4  The number of DPs fell from 2400 in Oct 2016 to 2161 in August 2019, with the smallest decline being for people with disabilities. This is for a variety of reasons but includes the administrative and employment consequences of taking responsibility for a DP.

18.5  50% of people use their DP to secure the services of a personal assistant.

18.6  Our understanding of the DP market still needs to be refined to enable its further development.

18.7   Challenges for this market include:

  • Improving our understanding of how people buy (or want to buy) individualised support and what they want to buy in terms of the range and flexibility of support options. This is especially difficult when people are using their own resources but conversations with providers should help us to gain greater understanding.
  • Improving our understanding of the range and quality of the personal assistant market.

18.8      We will support this change by:

  • revising our policy on Direct Payments by end 2019
  • strengthening our arrangements for talking with people who take all forms of individualised purchasing options, including the piloting of Individual Service Funds (ISFs) for up to 40 clients during 2019
  • using our new PA register to gather ‘soft intelligence’ about what types of support individual purchasers want and to build more effective relationships with this market
  • our ‘place-based’ work in communities (initiated in Kingsbridge, Cullompton, Ilfracombe, Totnes and Newton Abbot during 2019).

 

19. Carers (unpaid)

19.1  There are estimated to be 86,595 adult carers in Devon and this is projected to increase to 89,384 by 2024. We know about 30,000 of these carers.

19.2  Our carer support service, ‘Caring Well in Devon’, is provided by a consortium led by Westbank (Devon Carers) which secured the contract in 2018.

19.3  Challenges for ‘Caring Well in Devon’ include:

  • “hidden carers”, where people do not recognise themselves as carers, or where there is stigma or other inhibition on self-identification (for example where caring for someone with a substance misuse problem)
  • male carers and working age carers
  • carers in rural or coastal areas
  • carers from minority community groups, including gypsies and travellers who may be reluctant to have contact with services
  • LBGTQ+ carers, who may feel uncomfortable with accessing services.

19.4  Just over half of all known carers are retired, and half are in employment, volunteering or in education; we know proportionately fewer male than female carers; the ethnicity profile of carers broadly follows that of the Devon population; particularly at-risk carer groups include those aged 85+, carers with a learning disability in employment, and “sandwich” carers who care for people across a range of ages.

19.5 The main challenges for carers relates to the availability of:

  • community based replacement care in rural area, for example, affordable sitting services
  • bed-based replacement care, bookable in advance
  • day time replacement care – building or non-buildings based
  • personal assistants available to provide replacement care and
  • effective participation in care planning for their cared-for person.

19.6 We will support change in this market by:

  • supporting Devon Carers, who will work with the market to provide leadership in:
    • training for carers, especially in relation to caring safely and effectively
    • volunteer and staff – provided support, including at short notice, to support carers to prevent hospital admission or facilitate discharge
    • training for staff in carer awareness (for purchase by providers).
  • developing a new list of providers who are willing to offer replacement care from October 2019
  • reviewing our approach to carer breaks grants and testing new approaches
  • exploring lower cost options for sitting services and developing host family provision for daytime and short stay services.
  • making the best use of Technology Assisted Care and Support (TECS) to assist carers.
  • developing a carers passport scheme, which will include discounts and privilege access to community services, facilities and resources.

 

20. Replacement care

20.1   In 2018-19 753 people received replacement care in a care home or as a Direct Payment. The total spend was £3.05m, an increase of 2% on the preceding year. However, this spend was focused on increased numbers of people with a learning disability compared with other groups e.g. older people, where fewer people received support. Addressing this is a focus of our current work.

20.2   Replacement care is the outcome of a one-off or recurrent short-term service that specifically addresses the need of a carer for a break from caring responsibilities, or allows other carer needs to be met, by providing a service to the cared-for person.

Any short-term service which is explicitly intended to provide a break to the carer is included. This might include:

  • a service providing care or support in the person’s own home (including night sits); regulated or unregulated
  • a service which includes overnight accommodation for example in a care home, extra care housing or  a ‘Shared Lives Adult Placement’, or where a care and support provider utilises unregulated accommodation for example a hotel, B&B establishment or holiday rental
  • a day centre
  • care or support that allows the carer rest or a break during a holiday taken with the cared-for person
  • or, any combination of these.

20.3  The aim of our approach to replacement care is to:

  • increase carer resilience, reduce stress and prevent family breakdown
  • increase the choice of service models that provide replacement care that best meets their needs and individual circumstances
  • support people to be as independent as possible and by so doing reduce stress on carers. This is particularly the case for younger adults and for children with disabilities moving into adult life
  • ensure that there are enough, locally accessible and affordable services
  • ensure that those people with more complex needs usually requiring overnight accommodation, and often arising from multiple health conditions or disabilities, have access to services that can manage the complexity of need
  • provide greater assurance of the quality of replacement care services
  • ensure that replacement care can be booked well in advance.

20.4  The main challenge in meeting need for replacement care is:

  • to support the development of community and voluntary sector responses to carers that enable them to take a break, particularly in more rural areas
  • increasing the availability of bookable-ahead replacement care that supports the advanced planning of replacement care
  • increase the range of service models available for people and carers to choose from, including replacement care into the person’s own home, accommodation-based replacement care and replacement care in community-based services and other innovative models of provision
  • to develop a more transparent market for replacement care for the benefit of carers (both funded and private purchase)
  • improved access to replacement care services available at short notice or at the point of crisis
  • to improve the awareness of vacancies, quality and cost that supports purchasing of placements
  • improved understanding of needs to better describe demand and further stimulate market development.

20.5  Action to support this market will include:

  • introducing, in the autumn of 2019, a list of services that address the need for replacement care
  • working with the community and voluntary sectors to increase the availability of low-cost, non-regulated volunteer-provided sitting services
  • exploring the potential to innovate and find new models of replacement care, recognising the caution of providers to engage
  • exploring the potential for carer households to offer replacement care.

 

21. Equipment and Technology Enabled Care and Support (TECS)

21.1 In 2018, Devon County Council and the NHS published their joint TECS Strategy which defines technology enabled care and support as:

“the technologies that help people to manage and control their health and well-being and sustain independence”

21.2  Currently 1910 service users are receiving Technology Enabled Care and Support (TECS) via Millbrook Healthcare. This represents 17% of individuals receiving social care which is 10% below comparator authorities. We are though aiming to increase the number receiving TECS by 15% by 2022.

21.3  We are engaging with providers to promote TECS to promote independence and support provider efficiency/profitability. In addition we are developing the TECS website with info/advice.

21.4  Health and social care professionals use a ‘strengths-based’ approach in considering TECS solutions as part of their assessment, recognising that TECS is often an effective solution in mitigating the following risks:

RisksSolution
medication mis-managementmedication carousel that will alert when medication is due and will only dispense one dose at the allotted time
fallswearable fall detector that raises the alarm when someone falls
environmentDisability Discrimination Act (DDA) compliant transmitter – available in various forms – to alert someone to an incident, for example, smoke sensor or front door alarm
getting lost or wanderingGPS tracker or locator that can raise an alert to wandering and be set to a specific geo-fence
carer supportCare Assist or CAIR Buzz pager carried by supporter to alert to a specific sensor being activated
epilepsy or incontinenceepilepsy sensor watch, or incontinence bed sensors with alerts
other peopledoor entry sensor and alert
inability to carry out daily living tasksmemory aid apps

21.5 Providers who consider these risks and opportunities when working with service users in  their own homes will not only help to meet the service user’s outcomes but achieve efficiencies in their business and gain competitive advantage.  Providers can request an assessment by a health or social care practitioner (for those supported by DCC) for a TECS solution via Millbrook Healthcare.

21.6 We would also encourage providers to directly provide TECS solutions for individuals, not supported by DCC, sourced independently.  To support providers in doing so, we are developing a TECS  website called equipmentadvicedevon.org.uk with information and advice, and a self-assessment tool is now publicly available to help in identifying some simple TECS solutions that may help.

In the meantime, the Independent Living Centre (ILC) is separately commissioned to give advice and support on aids for daily living for members of the public and could give advice to Providers for an individual in their care including a TECS Buying Guide series.

21.7 Care Home Providers are encouraged to use TECS in their own service delivery models; whether via service management systems or by using TECS to promote independence.  If they choose to use TECS they can source this from any TECS provider.

21.8 We will encourage adoption of TECS solutions by:

  • Engaging with market provider organisations to promote the use of TECS within their own service improvement plans and accountable Boards.  We will include this requirement within any contracting frameworks in future and providers who embrace TECS solutions are likely to win more business.
  • Reviewing the TECS catalogue regularly against specific services, risks or outcomes to ensure it is fit for purpose & offers innovative solutions and encouraging Providers to let us know if they have specific areasthey would like the Council to review the catalogue against
  • Considering the potential for Providers to become Millbrook Prescribers and complete TECS assessments via the DILIS contract.
  • Commissioning arrangements for a mobile responder service (to respond to TECS alerts and meet the gap in the current service) are currently being reviewed with an options appraisal and development of a business case to support an agreed delivery model.  A market engagement event was held in September to inform our commissioning and budget planning for this service, and we would encourage providers who are interested in potentially delivering a mobile responder service to attend the event.  Following this a business case will be produced, and if agreed, a competitive tender exercise undertaken, with a view to a service commencing from April 2020.

 

22. Contract and commissioning milestones – summary

  • New Devon Care Homes framework by July 2020
  • Regional care home framework for learning disability clients with complex and intensive needs by July 2020
  • Establish personalised fee model from July 2020 for clients with learning disabilities/mental health condition
  • Carers contract runs to April 2023, plus two possible one year extensions
  • Living Well at Home contract runs to July 2021 with possible two further years extension
  • Accredited list of replacement care providers by autumn 2019/winter 2020
  • Determine future approach to the ‘supporting independence framework’ which runs until 30 September 2021
  • Supported living framework by autumn 2020
  • Commission a mobile responder service, starting from April 2020.

 

(Return to the Market Position Statement)

Last updated: 29/01/2020


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